MEDICARE: OMOLOLA KATE EBODA LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LC16364	MD

General Provider Information

NPI Number	:	1427758648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMOLOLA KATE EBODA LCPC

Provider Business Mailing Address
First Line	:	3625 SAPPHIRE RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-9401
Country	:	US
Telephone Number	:	404-232-5417
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 SAPPHIRE RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-9401
Country	:	US
Telephone Number	:	404-232-5417
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2023
Last Update Date	:	05/11/2026

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